上消化道出血史对肝移植治疗肝硬化门静脉高压的疗效分析
|
摘要
目的探讨上消化道出血史对肝移植治疗肝硬化门静脉高压(PHT)疗效的影响。方法回顾性分析2005年1月至2017年9月中国人民解放军联勤保障部队第九○○医院肝胆外科因肝硬化PHT行肝移植的受者临床资料,根据肝移植术前是否出现上消化道出血将其分为出血组和非出血组。观察指标为受者性别、年龄、术中出血量和输血量、住院时间、住院费用和肝移植前后肝功能指标。采用Wilcoxn符号秩和检验比较出血组与非出血组年龄、术中出血量和输血量等指标,采用成组t检验比较两组术前ALT、AST、总胆红素(TBil)、白蛋白(ALB)和凝血酶原时间(PT),采用两因素重复测量资料方差分析比较两组术后1周内各时间点肝功能指标,采用卡方检验比较两组性别和原发病情况。P<0.05为差异有统计学意义。结果最终纳入80例因肝硬化PHT接受肝移植治疗的受者,其中男性61例,女性19例,年龄7～71岁。原发病:乙型病毒性肝炎后肝硬化71例,胆汁性肝硬化5例,肝豆状核肝硬化2例,酒精性肝硬化2例。所有受者均采用原位下腔静脉逆灌注肝移植术。出血组(39例)与非出血组(41例)受者性别、年龄、原发病情况、术前肝功能指标、术中出血量和输血量、住院费用及住院天数差异均无统计学意义(P均>0.05)。出血组与非出血组术后各时间点ALT、AST、TBil、ALB和PT差异均无统计学意义(P均>0.05)。两组术后第3、5和7天血清ALT水平均低于术后第1天,两组术后第5和7天血清ALT水平均低于术后第3天,非出血组术后第7天血清ALT水平低于术后第5天(P均<0.05)。结论肝移植前是否存在上消化道出血史对肝移植治疗肝硬化PHT受者移植术后早期肝功能无影响。
Objective To investigate the effect of upper gastrointestinal hemorrhage on the efficacy of liver transplantation in the treatment of cirrhotic portal hypertension(PHT). Methods The clinical data of the recipients who underwent liver transplantation due to cirrhotic PHT from January 2005 to September 2017 in the Department of Hepatobiliary Surgery of the Chinese People′s Liberation Army 900 th Hospital of the Joint Logistics Team were analyzed retrospectively. All the recipients were divided into bleeding group and non-bleeding group according to whether they had the upper gastrointestinal bleeding occurred before liver transplantation. The parameters including gender, age, amount of intraoperative bleeding and blood transfusion, days of hospitalization, cost of hospitalization and the liver function indexes before and after liver transplantation were observed. Wilcoxn signed rank sum test was used to compare the age, the amount of intraoperative bleeding and blood transfusion, the cost of hospitalization and the days of hospitalization between the two groups. ALT, AST, total bilirubin(TBil), albumin(ALB) and prothrombin time(PT) between the two groups were compared by group t test. Two-factor repeated data analysis of variance was used to compare the liver function indexes at each time point within 1 week after liver transplantation between the two groups. Chi-square test was used to compare the gender and primary diseases of the two groups. P<0.05 means statistically significant. Results A total of 80 cases(61 males and 19 females, aged 7-71 years old) underwent liver transplantation due to cirrhotic PHT. Primary diseases included 71 cases of posthepatitic cirrhosis, 5 cases of biliary cirrhosis, 2 cases of hepatolenticular cirrhosis and 2 cases of alcoholic cirrhosis. All subjects underwent orthotopic inferior vena cava reverse perfusion liver transplantation. There was no significant difference between the bleeding group(39 cases) and the non-bleeding group(41 cases) in gender, age, primary disease, preoperative liver function indexes, amount of intraoperative bleeding and blood transfusion, cost of hospitalization and days of hospitalization(P all>0.05). There was no significant difference in ALT, AST, TBil, ALB and PT between the two groups at all time points after operation(P all>0.05). The levels of serum ALT on the 3 rd, 5 th and 7 th day after operation in both groups were lower than those on the 1 st day after operation. The levels of serum ALT on the 5 th and 7 th day after operation in both groups was lower than those on the 3 rd day after operation. The level of serum ALT on the 7 th day after operation was lower than that on the 5 th day after operation in the non-bleeding group(P all>0.05). Conclusion The history of upper gastrointestinal bleeding before liver transplantation had no effect on the early liver function after liver transplantation in the treatment of cirrhotic PHT.
Objective To investigate the effect of upper gastrointestinal hemorrhage on the efficacy of liver transplantation in the treatment of cirrhotic portal hypertension(PHT). Methods The clinical data of the recipients who underwent liver transplantation due to cirrhotic PHT from January 2005 to September 2017 in the Department of Hepatobiliary Surgery of the Chinese People′s Liberation Army 900 th Hospital of the Joint Logistics Team were analyzed retrospectively. All the recipients were divided into bleeding group and non-bleeding group according to whether they had the upper gastrointestinal bleeding occurred before liver transplantation. The parameters including gender, age, amount of intraoperative bleeding and blood transfusion, days of hospitalization, cost of hospitalization and the liver function indexes before and after liver transplantation were observed. Wilcoxn signed rank sum test was used to compare the age, the amount of intraoperative bleeding and blood transfusion, the cost of hospitalization and the days of hospitalization between the two groups. ALT, AST, total bilirubin(TBil), albumin(ALB) and prothrombin time(PT) between the two groups were compared by group t test. Two-factor repeated data analysis of variance was used to compare the liver function indexes at each time point within 1 week after liver transplantation between the two groups. Chi-square test was used to compare the gender and primary diseases of the two groups. P<0.05 means statistically significant. Results A total of 80 cases(61 males and 19 females, aged 7-71 years old) underwent liver transplantation due to cirrhotic PHT. Primary diseases included 71 cases of posthepatitic cirrhosis, 5 cases of biliary cirrhosis, 2 cases of hepatolenticular cirrhosis and 2 cases of alcoholic cirrhosis. All subjects underwent orthotopic inferior vena cava reverse perfusion liver transplantation. There was no significant difference between the bleeding group(39 cases) and the non-bleeding group(41 cases) in gender, age, primary disease, preoperative liver function indexes, amount of intraoperative bleeding and blood transfusion, cost of hospitalization and days of hospitalization(P all>0.05). There was no significant difference in ALT, AST, TBil, ALB and PT between the two groups at all time points after operation(P all>0.05). The levels of serum ALT on the 3 rd, 5 th and 7 th day after operation in both groups were lower than those on the 1 st day after operation. The levels of serum ALT on the 5 th and 7 th day after operation in both groups was lower than those on the 3 rd day after operation. The level of serum ALT on the 7 th day after operation was lower than that on the 5 th day after operation in the non-bleeding group(P all>0.05). Conclusion The history of upper gastrointestinal bleeding before liver transplantation had no effect on the early liver function after liver transplantation in the treatment of cirrhotic PHT.
引文
1 Orloff MJ, Isenberg JI, Wheeler HO, et al. Hepatocellular carcinoma in a randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis[J]. Am J Surg, 2012, 203(2): 182- 190.
2 Garcia- Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis[J]. N Engl J Med, 2010, 362(9): 823- 832.
3 Coellho FF, Perini MV, Kruger JA, et al. Management of variceal hemorrhage: current concepts[J]. Aro Bras Cir Dig, 2014, 27(2): 138- 144.
4 刘坤鹏, 刘士会. 肝硬化门静脉高压症的外科治疗进展[J]. 中华全科医学, 2014, 12(10): 1654- 1656.
5 Bari K. Treatment of portal hypertension[J]. World J Gastroenterol, 2012, 18(11): 1166- 1175.
6 王贵强, 王福生, 成军, 等. 慢性乙型肝炎防治指南(2015年版)[J/CD]. 中国肝脏病杂志:电子版, 2015, 7(3): 1- 18.
7 中华医学会外科学分会门静脉高压学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血的诊治共识(2015版)[J]. 中华外科杂志, 2015, 53(12):917-921.
8 Poza Cordon J, Froilan Torres C, Burgos Garcia A, et al. Endoscopic management of esophageal varices[J]. World J Gastrointest Endosc, 2012, 4(7): 312- 322.
9 Vorobioff JD, Groszmann RJ. Prevention of portal hypertension: from variceal development to clinical to decompensation[J]. Hepatology, 2015, 61(1): 375- 381.
10 Merion RM, Wolfe RA, Dykstra DM, et al. Longitudinal assessment of mortality risk among candidates for liver transplantation[J]. Liver Transpl, 2003, 9(1): 12- 18.
11 Lai JC, Dodge JL, Sen S, et al. Functional decline in patients with cirrhosis awaiting liver transplantation: Results from the functional assessment in liver transplantation (FrAILT) study[J]. Hepatology, 2016, 63(2): 574- 580.
12 Boin Ide F, Leonardi MI, Udo EY, et al. The application of MELD score in patients submitted to liver transplantation: a retrospective analysis of survival and the predictive factors in the short and long term[J]. Arq Gastroenterol, 2008, 45(4): 275- 283.
13 Wang X, Lin SX, Tao J, et al. Study of liver cirrhosis over ten consecutive years in Southern China[J]. World J Gastroenterol, 2014, 20 (37) : 13546- 13555.
14 Eto R, Oka M. Effects of hemofiltration on liver regeneration after hepatectomy[J]. Hepatogastroenterology, 2010, 57(104): 1469- 1473.
15 中国医师协会器官移植医师分会, 中华医学会器官移植学分会. 中国肝癌肝移植临床实践指南(2018版)[J/CD]. 中华移植杂志: 电子版, 2018, 12(4):145- 150.
16 Leong J. Im GY. Evaluation and selection of the patient with alcoholic liver disease for liver transplant[J]. Clin Liver Dis, 2012, 16(4): 851- 863.
17 Bekker J, Ploem S, de Jong KP. Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors[J]. Am J Transplant, 2009, 9(4): 746- 757.
18 Stewart ZA, Locke JE, Segev DL, et al. Increased risk of graft loss from hepatic artery thrombosis after liver transplantation with older donors[J]. Liver Transpl, 2009, 15(12): 1688- 1695
19 Settmacher U, Nussler NC, Glanemann M, et al. Venous complications after orthotopic liver transplantation[J]. Clin Transplant, 2000, 14(3): 235- 241.
20 Sotiropoulos GC, Vernadakis S, Paul A, et al. Single- center experience on liver transplantation for model for end- stage liver disease score 40 patients[J]. Dig Dis Sci, 2016, 61(11): 3346- 3353.
21 Zhe C, Jian- wei L, Jian C, et al. Laparoscopic versus open splenectomy and esophagogastric devascularization for bleeding varices or severe hypersplenism: a comparative study[J]. J Gastrointest Surg, 2013, 17(4): 654- 659.
22 Zhang Y, Wen TF, Yan LN, et al. Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization[J]. World J Gastroenterol, 2012, 18(15) : 1834- 1839.
23 Deng MH, Liu B, Fang HP, et al. Predictive value of D- dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus- related cirrhosis[J]. World J Gastroenterol, 2007, 13(48): 6588- 6592.
24 Rana A, Hardy MA, Halazun KJ, et al. Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation[J]. Am J Transplant, 2008, 8(12): 2537- 2546.
25 Dutkowskli P, Oberkofler CE, Slankamenac K, et al. Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end- stage liver disease era[J]. Ann Surg, 2011, 254(5): 745- 753.
26 Bang SR, Ahn HJ, Kim GS, et al. Predictors of high intraoperative blood loss derived by simple and objective method in adult living donor liver transplantation[J]. Transplant Proc, 2010, 42(10): 4148- 4150.
27 de Boer MT, Christensen MC, Asmussen M, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation[J]. Anesth Analg, 2008, 106(1): 32- 44.
28 Boin IF, Leonardi MI, Luzo AC, et al. Intraoperative massive transfusion decreases survival after liver transplantation[J]. Transplant Proc, 2008, 40(3): 789- 791.
29 Zimring JC. Fresh versus old blood are there differences and do they matter?[J]. Hematology, 2013, 2013(1): 651- 655.
2 Garcia- Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis[J]. N Engl J Med, 2010, 362(9): 823- 832.
3 Coellho FF, Perini MV, Kruger JA, et al. Management of variceal hemorrhage: current concepts[J]. Aro Bras Cir Dig, 2014, 27(2): 138- 144.
4 刘坤鹏, 刘士会. 肝硬化门静脉高压症的外科治疗进展[J]. 中华全科医学, 2014, 12(10): 1654- 1656.
5 Bari K. Treatment of portal hypertension[J]. World J Gastroenterol, 2012, 18(11): 1166- 1175.
6 王贵强, 王福生, 成军, 等. 慢性乙型肝炎防治指南(2015年版)[J/CD]. 中国肝脏病杂志:电子版, 2015, 7(3): 1- 18.
7 中华医学会外科学分会门静脉高压学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血的诊治共识(2015版)[J]. 中华外科杂志, 2015, 53(12):917-921.
8 Poza Cordon J, Froilan Torres C, Burgos Garcia A, et al. Endoscopic management of esophageal varices[J]. World J Gastrointest Endosc, 2012, 4(7): 312- 322.
9 Vorobioff JD, Groszmann RJ. Prevention of portal hypertension: from variceal development to clinical to decompensation[J]. Hepatology, 2015, 61(1): 375- 381.
10 Merion RM, Wolfe RA, Dykstra DM, et al. Longitudinal assessment of mortality risk among candidates for liver transplantation[J]. Liver Transpl, 2003, 9(1): 12- 18.
11 Lai JC, Dodge JL, Sen S, et al. Functional decline in patients with cirrhosis awaiting liver transplantation: Results from the functional assessment in liver transplantation (FrAILT) study[J]. Hepatology, 2016, 63(2): 574- 580.
12 Boin Ide F, Leonardi MI, Udo EY, et al. The application of MELD score in patients submitted to liver transplantation: a retrospective analysis of survival and the predictive factors in the short and long term[J]. Arq Gastroenterol, 2008, 45(4): 275- 283.
13 Wang X, Lin SX, Tao J, et al. Study of liver cirrhosis over ten consecutive years in Southern China[J]. World J Gastroenterol, 2014, 20 (37) : 13546- 13555.
14 Eto R, Oka M. Effects of hemofiltration on liver regeneration after hepatectomy[J]. Hepatogastroenterology, 2010, 57(104): 1469- 1473.
15 中国医师协会器官移植医师分会, 中华医学会器官移植学分会. 中国肝癌肝移植临床实践指南(2018版)[J/CD]. 中华移植杂志: 电子版, 2018, 12(4):145- 150.
16 Leong J. Im GY. Evaluation and selection of the patient with alcoholic liver disease for liver transplant[J]. Clin Liver Dis, 2012, 16(4): 851- 863.
17 Bekker J, Ploem S, de Jong KP. Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors[J]. Am J Transplant, 2009, 9(4): 746- 757.
18 Stewart ZA, Locke JE, Segev DL, et al. Increased risk of graft loss from hepatic artery thrombosis after liver transplantation with older donors[J]. Liver Transpl, 2009, 15(12): 1688- 1695
19 Settmacher U, Nussler NC, Glanemann M, et al. Venous complications after orthotopic liver transplantation[J]. Clin Transplant, 2000, 14(3): 235- 241.
20 Sotiropoulos GC, Vernadakis S, Paul A, et al. Single- center experience on liver transplantation for model for end- stage liver disease score 40 patients[J]. Dig Dis Sci, 2016, 61(11): 3346- 3353.
21 Zhe C, Jian- wei L, Jian C, et al. Laparoscopic versus open splenectomy and esophagogastric devascularization for bleeding varices or severe hypersplenism: a comparative study[J]. J Gastrointest Surg, 2013, 17(4): 654- 659.
22 Zhang Y, Wen TF, Yan LN, et al. Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization[J]. World J Gastroenterol, 2012, 18(15) : 1834- 1839.
23 Deng MH, Liu B, Fang HP, et al. Predictive value of D- dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus- related cirrhosis[J]. World J Gastroenterol, 2007, 13(48): 6588- 6592.
24 Rana A, Hardy MA, Halazun KJ, et al. Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation[J]. Am J Transplant, 2008, 8(12): 2537- 2546.
25 Dutkowskli P, Oberkofler CE, Slankamenac K, et al. Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end- stage liver disease era[J]. Ann Surg, 2011, 254(5): 745- 753.
26 Bang SR, Ahn HJ, Kim GS, et al. Predictors of high intraoperative blood loss derived by simple and objective method in adult living donor liver transplantation[J]. Transplant Proc, 2010, 42(10): 4148- 4150.
27 de Boer MT, Christensen MC, Asmussen M, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation[J]. Anesth Analg, 2008, 106(1): 32- 44.
28 Boin IF, Leonardi MI, Luzo AC, et al. Intraoperative massive transfusion decreases survival after liver transplantation[J]. Transplant Proc, 2008, 40(3): 789- 791.
29 Zimring JC. Fresh versus old blood are there differences and do they matter?[J]. Hematology, 2013, 2013(1): 651- 655.